Knowledge & Resource Center
Welcome to the Knowledge & Resource Center, a collection of transitions of care tools that seek to improve care transitions and positively impact health outcomes.
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This portion of the Center below, features tools and resources submitted to the Essential Resource Program, which address a specific transition of care issue; assist patients, caregivers, healthcare providers, and others with respect to transitions of care; and/or positively impact patient outcomes. Submitted tools and resources must also address one or more of the NTOCC Seven Principles, principles by which providers and organizations must adhere to improve transitions of care, as well as the NTOCC Seven Critical Interventions, key elements found in evidence-based care interventions. We hope you find the following tools and information useful.
The seven key elements was created by NTOCCs 32 member organizations to help health systems adopt a care transitions bundle from each of the 7 categories, for their individual needs. This resource has been updated for 2022 to reflect ever changing healthcare industry and we have added an appendix for more clarity.
Schizophrenia Pathway
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Learning Lab Transitions of Care (ToC)
Transitioning from inpatient to outpatient care is a time of great stress and vulnerability for patients
with schizophrenia. All too often, patients fail to follow-up with their outpatient care team or remain
adherent with their established medical management and antipsychotic medications which can lead to
relapses, rehospitalizations, and decreased quality of life.
You can Download this schizophrenia transitions of care pathway tool to learn the latest information and strategies to manage schizophrenia care across the inpatient-outpatient spectrum and advance patient-centered schizophrenia care.
Eosinophilic Esophagitis Pathway
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Patients who are diagnosed with Eosinophilic Esophagitis (EoE) often find their care journey long and frustrating with unanswered questions about their condition. EoE is a chronic, T helper type 2 (Th2)–associated inflammatory disease characterized by marked eosinophilic inflammation of the esophagus (defined by a peak count of ≥ 15 eosinophils per high-powered field [eos/hpf] of esophageal biopsy tissue). EoE was recognized in the 1990s as a clinicopathologic disorder, which is relatively recent compared with the identification of other allergic diseases such as asthma and allergic rhinitis. To address the needs of providers and patients navigating the complexities of safely managing EoE at home, monitoring symptoms, maintaining communication between healthcare providers and patients, and navigating follow-up care coordination, PRIME and NTOCC work together to develop Collaborative Pathways for Successful Transitions of Care for Patients With Eosinophilic Esophagitis, to support care transitions for patients with EoE.
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Developed by a steering committee of thought leaders from different practice and professional settings, the pathway provides strategies, resources, and tools that enable multidisciplinary transitions of care across healthcare settings. Providers will be able to identify and implement collaborative team-based approaches to EoE management, from diagnosis through ambulatory and acute care coordination. The pathway assists with improving care options and transitions to enhance the quality of the patient’s journey plus point-of-care resources for patient education and health management for use in daily practice.
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The pathway is supported through an educational grant from Takeda Pharmaceuticals U.S.A., Inc.
Non-Opioid Pain Management
Non-Opioid Pain Management Resources
nonopioidchoices.org is dedicated to increasing awareness of and access to non-opioid approaches to pain management for patients and providers. Visit nonopioidchoices.org for background information and to lend your voice to promote these approaches.
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TAKING CARE OF MY PAIN MANAGEMENT RESOURCE NOW AVAILABLE – Tuesday, August 6, 2019
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NTOCC, in collaboration with various organizations and healthcare leaders, including Quality Insights and Allied Against Opioid Abuse, has developed “Taking Care of My Pain Management,” a consumer tool for providers, patients, and family caregivers. This resource enables patients and caregivers to discuss opioid use and management concerns with providers. It includes two additional resources: “Know Your Rights, Risks and Responsibilities” and “About Prescribing Naloxone,” which provide information and support for understanding and managing opioid prescriptions.
Heart Failure Pathway
PRIME® Education Heart Failure Pathway
Despite significant treatment advances, new evidence, and recently updated guidelines, high rates of hospital readmissions and poor outcomes persist for patients with heart failure. Experts recognize the remarkable potential to reduce unnecessary hospitalizations and improve patient outcomes through effective interventions at critical transition points to bridge gaps in care. Developed in partnership with the National Transitions of Care Coalition (NTOCC) and led by a multidisciplinary advisory board, this Heart Failure Transitions of Care (TOC) pathway provides essential interventions and tools to support system leaders and the interprofessional care team - including patients and their caregivers.
Clostridioides Difficile Pathway
PRIME® Education Clostridioides Difficile Pathway
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The incidence and severity of Clostridioides difficile infection (CDI) has increased markedly, placing a substantial economic burden on patients, caregivers, hospitals, and healthcare systems. As patients with primary or recurrent CDI transition across care settings, gaps in testing, diagnosis, treatment, and care coordination magnify the problem and contribute to poor patient outcomes and escalating costs. PRIME and NTOCC worked with an interprofessional steering committee to devleop a downlaodable guide designed to support effective care transitions and evidence-based CDI management.
Our Services
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PAH Pathway
PRIME® Education PAH Pathway is a transitions of care white paper that was developed by NTOCC and Case Management Society of America (CMSA) for system leaders and interprofessional clinical team members who treat and manage patients with PAH.
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Joint Commission Portal
The Joint Commission's Transitions of Care Portal is a valuable source of information from The Joint Commission enterprise and other healthcare organizations, related to the topic of transitions of care (the movement of patients between various health care settings.)
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IPF White Paper
PRIME® Education IPF White Paper is a transitions of care white paper that incorporates essential interventions and tools designed to ensure effective and safe transitions of care for patients with IPF across healthcare settings.
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DVT/PE Transitions
Improving DVT/PE Transitions of Care, offered by Janssen and Johnson & Johnson through their CarePath|Healthy Engagements program, is a resource designed to help prescribers, care coordinators, nurses, and other healthcare professionals facilitate the transition of care for patients being discharged from the hospital after a deep vein thrombosis (DVT) or pulmonary embolism (PE) diagnosis.
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Diabetes Transitions Kit
The Diabetes Transitions of Care Kit, offered by Janssen and Johnson & Johnson through their CarePath|Healthy Engagements Program, provides tools and resources for providers/staff members who support care transitions for patients with Type 2 Diabetes (T2D) and multiple chronic conditions in hospitals/health systems.